Many problems ahead for ACA

Now that the Affordable Care Act in most of its bulk has been declared constitutional by the Supreme Court ("Reform moves ahead," June 29), there are numerous practical stumbling blocks to its implementation.

According to the mandate, everyone in America should have health insurance or else they will be taxed as penalty. The enforcement of this penalty is supposed to occur through the already-overburdened U.S. Internal Revenue Service. The government will have to expand the IRS bureaucracy, its software capacity and its powers, extensively to enforce the mandate. In Massachusetts where RomneyCare is in effect, the state takes scofflaws of its health care mandate to court to enforce the law. Will the federal government do that and waste precious dollars to take on citizens, who don't pay the fines due, for defying the law?

What happens to the people who are in violation of the law when they land in emergency rooms across the nation? Will hospitals be recruited to enforce the law by reporting such scofflaws to the government? Will people without health insurance continue to get emergency care if they have not paid up their penalties and if they are fugitives from this law?

What of those folks who don't file income taxes? How will the law be enforced against them?

I am a doctor in private practice and I see a lot of Medicaid patients. I know my patients undergo hell to get and keep their Medicaid. The paper work is burdensome, the bureaucracy is overworked, underpaid and nasty to its clients. The poor and sick who need Medicaid are not adept at filling out the numerous eligibility and other complicated forms required to stay on Medicaid. I am sure the subsidized portion of the Affordable Care Act will be a nightmare to administer and navigate, giving room for the type of fraud that has beset Medicaid and Medicare. The thought that goes through my mind repeatedly is that we will be creating one more, in all likelihood, inept bureaucracy, with burdens of huge documentation and verification, that could sink the country's treasury.

Aside from the fact there will continue to be numerous uninsured Americans, despite the ACA, the ranks of insured Americans will swell. Anyone who has been in a hospital emergency room recently can testify to long waits and rude encounters with overwhelmed providers. Hospitals continue to be understaffed and we cannot mint decent healthcare providers overnight. Doctors' offices too are crowded and each patient is getting cheated in terms of time spent with their providers. This leads to mistakes in diagnosis and treatment. The Affordable Care Act does not address malpractice reform. At a time when we need more health care workers, medicine as a profession, is being enervated and totally squeezed by insurers and administrators. Providers are demoralized and weary. Many quit and I don't see how the Obama administration or any state can come up with enough health care workers to care for the newly insured, who are also probably quite sick, when the atmosphere for providers of care is neither welcoming nor bearable.

Most important, we have a critical shortage of certain medicines for cancer and other ailments. We also have an unconscionable rationing of care, as promulgated, monitored and enforced by private health insurers. Providers have to spend hours on the telephone fighting insurers, so their patients can get essential medications and tests. Insurers cherry pick what lab tests and interventions they will pay for, often after the tests have been done. Patients suffer due to the cost of these denials, even as insurers turn patients against doctors and hospitals against patients in a wild chase for unpaid bills.

I know those in favor of the Affordable Care Act will say that none of these kinks are insuperable. They can be unknotted as the law takes effect and all will be well. Of course, it is impossible to address every negative effect of what one is about to do before the negatives ever happen. But in the case of the Affordable Care Act, the administration has been all rosy and I suspect none of the negatives I have mentioned have been thought out. President Barack Obama, his team and the Maryland Democratic Party's apologists and enthusiasts for the Affordable Care Act are simply unprepared for the ills yet to follow from its implementation.

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